Symmetrical Peripheral Gangrene Associated with Low Output Cardiac Failure


      Symmetrical peripheral gangrene (SPG) is a rare clinical condition with acute, symmetrical ischemia of two or more extremities leading to gangrene in the absence of large vessel obstruction or vasculitis. We present a case of SPG presenting in the setting of severely depressed cardiac ejection fraction.

      Case Description

      Patient is a 64-year-old man referred to our emergency department from an outside hospital for management of liver failure and bilateral necrotic toes. His past medical history and surgical history were unremarkable. He drank 3-4 beers and 2-3 glasses of hard liquor daily. He had dry and gangrenous second through fifth toes and densely cyanotic first toes bilaterally. (Figure 1) Dorsalis pedis and posterior tibialis pulses were present bilaterally on palpation. His liver function test (LFT) was deranged (Total bilirubin: 35.0 mg/dL, direct bilirubin: >10.0 mg/dL, AST: 309 IU/L, ALT: 295 IU/L). Echo showed ejection fraction of 10 percent with global hypokinesis and severe left ventricular enlargement but no embolus. His brain natriuretic peptide was 18,984 pg/mL (reference range: < 125 pg/mL). Left heart catheterization showed non-obstructive coronary artery disease. Right heart catheterization showed elevated pulmonary artery pressures and filling pressures with cardiac index of 1.28. He was started on dobutamine infusion. His deranged LFT and liver failure was related to hypoperfusion of liver. His necrotic toes were thought to be secondary to decreased peripheral perfusion and redistribution to vital organs in the setting of acute heart failure after normal arteries were visualized in computed tomography angiography of chest/abdomen/pelvis and Doppler ultrasound of legs.


      Diagnosis should be suspected in patients with bluish discoloration of extremities and elevated lactate levels. Various infective and noninfective factors are responsible for development of SPG. Among them, cardiac conditions like myocardial infarction, myocardial infarction with coronary artery bypass graft and ventricular septal defect repair, ball-valve thrombus with mitral stenosis, paroxysmal ventricular tachycardia, ventricular pseudoaneurysm and severe heart failure have been associated with SPG.


      SPG is associated with significant mortality and morbidity with an alarmingly high rate of amputation in survivors. Awareness of this condition and association with low flow state can help diagnose this condition early with prompt treatment for early recovery.